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Full Service Appeals Processing
 The fiduciary duties and responsibilities under ERISA are the highest duties under law. The ERISA fiduciary rules requires those who are involved as fiduciaries of ERISA-governed benefit plans to discharge their duties "with the care, skill, prudence, and diligence under the circumstances then prevailing that a prudent man acting in a like capacity and familiar with such matters would use in the conduct of an enterprise of a like character and with like aims.“ ERISA Section 404(a)(1).
With respect to the benefit claim process, the plan Fiduciary is responsible to the plan and its participants and beneficiaries, and must:
- Follow all claims procedures and deadlines.
- Diligently respond, in writing, to all written communications.
- Gather information as needed, including information and evidence gathered from the claimant and independent sources such as internal staff, actuaries (for retirement plans, as needed), medical reviewers or providers (disability and health plans) and develop and complete the content of each claim to develop an administrative record of the claim.
- Analyze and review completely each record and take additional steps to correct any procedural or substantive defects or inconsistencies.
- Obtain updated or additional information or data as the analytical process evolves, and as it may be warranted.
- Provide a written decision that is consistent with the plan terms, the facts and information gathered by a thorough process, and fully compliant with the plan and ERISA Section 503 and the regulations at 29 C.F.R. § 2560.503-1.
To accomplish full service final claim appeal processing, in accordance with these important ERISA responsibilities:
- CAFS employs highly skilled, highly educated, degreed professionals.
- All employees undergo continuous training which covers, in detail: ERISA basics, ERISA fiduciary law under Section 404, benefits plan types and terms, ERISA claims procedures under ERISA Section 503 and regulations at 29 C.F.R. §2960.503-1, judicial and civil process, ERISA enforcement, case law and more.
- Claims process and plan document details are tailored to the specific plan sponsor and the terms of the benefit plan for which CAFS is providing individual claim appeal processing.
- CAFS maintains and continually improves its process and review systems based on developments in the law and any changes to plan terms.
- Appeals and decision-making are reviewed by additional resources within CAFS’ that include CAFS’ own legal counsel routinely as appropriate, to ensure quality and consistency.
- CAFS coordinates with plan sponsors, outside professionals and consultants, medical review companies, and claims administrators as needed or warranted.
Each individual claim appeal is processed in accordance with the plan sponsor's specific needs in a customized, complete integrated process that includes the following actions:
- CAFS fully investigates the facts and compiles a complete administrative record, including the plan document and SPD.
- CAFS assesses the procedural status of the appeal, dockets all deadlines and documents the procedural history of the claim.
- CAFS evaluates the applicable plan terms and standards.
- CAFS communicates with the claimant regarding the claims procedures under the plan, consistent with the plan and its sponsor’s requirements.
- CAFS reviews and assesses the factual findings in the record and gathers additional facts as may be warranted by the circumstances from internal staff, outside professionals as may be needed, including actuaries (pension), medical reviewers (medical and disability) and sponsor’s counsel if needed.
- CAFS evaluates new facts, considers additional evidence to be obtained and coordinates the pursuit of this additional information with the claimant and the plan sponsor.
- CAFS completes the development of the administrative record under the applicable claims procedure.
- CAFS analyzes the factual record under the terms of the plan.
- CAFS makes analytic findings based upon the facts in the administrative record and the plan terms.
- CAFS creates a thorough, detailed, written decision, and notifies the claimant and the sponsor.
- CAFS responds to any follow up communications from the claimant.
- CAFS supports the sponsor's efforts to enforce any adverse decision, including assisting in litigation, discovery, and any further needs of the sponsor relative to the claim process.
Claim Appeal Fiduciary Services - Integrity for All Concerned
The use of CAFS provides complete advantages for the plan sponsors, internal staff and the claimants themselves. As a result of this quality approach, plan sponsors are at an advantage when they employ CAFS to act as the independent ERISA fiduciary to process ERISA plan final claim appeals. The investment in this independence provides a clear return, because it provides the quality and skilled service that is needed to relieve the burdens on human resource or other staff, eliminates conflict of interest, reduces the likelihood of process issues, and brings a skilled and capable independent third party to improve final claim appeal processing, which solidifies the financial integrity of these important plans for all concerned.
To learn more, please contact us for details of how CAFS is a better alternative for the processing of claim appeals for all of your ERISA-governed employee benefit plans, including pension and 401(k) plans, short and long term disability plans, health plans and severance or other types of ERISA-governed plans.
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